Carpal Tunnel Syndrome is the most common pathology as seen in United States. It has been noted that the pathology occurs in varied individuals with different work background fields. The paper will help us to understand that the pathology is not only associated with the work related backgrounds but are congenitally present. The paper will also help us to understand that the pathological symptoms can be exacerbated by certain activities. The paper will present a brief concept of the imaging studies used to diagnose carpal tunnel syndrome and not limiting to that but will also help us to understand the treatment of carpal tunnel with the help of those imaging studies.
CARPAL TUNNEL SYNDROME: Carpal tunnel syndrome is regarded as the most common entrapment neuropathy and its prevalence can be estimated by 2.7 to 5.8% as seen in the adult population ( LeBlanc & Chestia, 2011). According to the survey in United Kingdom the mean crude ratio of carpal tunnel was regarded to be found in 329 cases per 100,000 person - years along with the standardized incidence ranging to 276 (LeBlanc & Chestia, 2011). Carpal tunnel syndrome is often associated with repetitive overuse-type of injuries caused by repetitive motion and is mostly work related (LeBlanc & Chestia, 2011).
ETIOLOGICAL FACTORS: The exact etiological factors are unknown. However the following etiological factors have been considered. (LeBlanc & Chestia, 2011).
Repetitive Maneuvers
Obesity
Pregnancy
Arthritis
Hypothyroidism
Diabetes Mellitus
Trauma
Mass Lesions
Amyloidosis
Sarcoidosis
Multiple Myeloma and
Leukemia
SYMPTOMS: According to LeBlanc & Chestia, (2011), the patient with carpal tunnel syndrome shows pain and paresthesia in the hand mainly along the distribution of the median nerve i.e along the course of thumb, index finger and the middle finger. Gradually the symptoms of pain and paresthesia spreads towards the forearm, arm and even to the shoulder region. (LeBlanc & Chestia, 2011). The patient might report of the feeling of swelling and the fingers feeling useless, however the demarcation of swelling is not present ( LeBlanc & Chestia, 2011). The patient reports of difficulty in performing activities that requires grasp and the patient also complains frequent pain at the night time (LeBlanc & Chestia, 2011).
PHYSICAL EXAMINATION: Physical examination shows ecchymosis or abrasion in the wrist region due to acute injury to the tissue including the median nerve. (LeBlanc & Chestia, 2011). Thenar eminence atrophy might be present and is mostly associated with carpometacarpal arthritis or neuropathy. (LeBlanc & Chestia, 2011). Hypalgesia in the palmar region of the hand with diminished strength and relative weakness of the abductor pollicis brevis muscle is present due to entrapment of the median nerve (LeBlanc & Chestia, 2011). Phalens sign, tinnel sign, square wrist sign and above mention data can be utilized to a diagnostic value of history and physical examination of the carpal tunnel syndrome (LeBlanc & Chestia, 2011).
IMAGING STUDY AND THEIR SCOPES RELATED IN CARPAL TUNNEL SYNDROME
Imaging studies including MRI and Ultrasonography has played important role in the diagnosis and treatment of carpal tunnel syndrome. MRI and Ultrasonography has not only been used in diagnosing the presence of median nerve entrapment or related pathologies but furthermore the paper will state that ultrasound has also helped in healing carpal tunnel syndrome. There are varied cases presented below which shows the diagnostic validity of MRI and ultrasonography in CTS (carpal tunnel syndrome.
As in the article stated by Nguyen et al (2012), a 52 year old man shows paresthesia which is intermittent in nature and is present from the last 10 years along the course of the median nerve distribution. The patient also complains of snapping of the fingers and states that driving and typing exacerbates the symptoms. During the examination Nguyen et al (2012) found the unusual case where instead of the atrophy of the thenar eminences there was hypertrophy and increase in the mass buldge of the thenar eminences.
An MRI was performed to solve the mystery of the hypertrophy of the thenar eminences. The MRI shows linear strands of fat infiltrating into the thenar muscles which is different from the diffuse fibro fatty change associated with advance muscular atrophy as seen in regular CTS. The MRI shows globular enlargement of the median nerve and linear cable like appearance of the nerve fascicles surrounding the fat (Nguyen et al, 2012).
The other study is provided by Fujji et al (2009), where imaging studies have played a tremendous role in classifying the presence of epithelial sarcoma which arises directly from the perineural sheath of the median nerve and mimics the sign and sympotms of the carpal tunnel syndrome. Here the case is presented of a 33 year old man who complains of pain and weakness in the course and area of distribution of the Media nerve (Fujji et al, 2009). As the epithelial sarcoma was gradually progressing and the nodule formation where noted later, the patient was first treated conservatively, thinking the symptoms manifested of CTS. (Fujji et al, 2009). The patient then noticed the presence of nodules on the forearm region and a MRI was then performed.
Epithelial sarcoma is indolent in growth and is slow growing tumor. They are one of the kinds which are rare and malignant in nature however very aggressive on occasions (Fujji et al, 2009). As their clinical manifestations are unpredictable, according to mayo clinic 38% of patient had at least recurrence and 47% of patient had metastatic lesions and 27% of the patient dies out of the disease. So in the above mention case CTS but also helped to treat the underlying lesions.
The other study was performed by Cartwright et al (2011). The study uses the Neuromuscular ultrasound to assess the changes that occur in median nerve followed by a steroid injection. In this study participants were injected the steroid injection after conducting the nerve conduction velocity study (Cartwright et al, 2011). The affected wrist was then examined with the ultrasound technique at the end of 1 week, 1 month and 6 month respectively. The ultrasound examination included measurement of the median nerve cross-sectional area at the distal wrist crease (DWC) and mid-forearm, as well as assessment of median nerve echogenicity, mobility, and vascularity at the DWC. (Cartwright et al, 2011). The ultrasound imaging was performed using an Esoate Ultrasound Device. The results of the ultrasound study showed decrease in the median nerve cross sectional area and helped the clinician to understand the timeframe of the treatment and also to evaluate the individuals who have showed failed response to the CTS treatment. (Cartwright et al, 2012). The only limitation of this study was the small sample size, therefore the study couldn't produce the probability of its usefulness on larger populations.
As I have narrated in my thesis statement that the CTS can also be caused by the congenital presences of the atypical muscles and this is noted in the case study of a recreational climber. Here the climber is present with anomalous rare presence of the muscle which is further a cause leading to CTS. Here the recreation climber, who is a male of 41 year of age presents with the symptoms of pain and paresthesia in his palmar aspects (Unglaub et al, 2010). The atypical muscle mass is seen in MRI and is the typical cause of CTS. The patient exercises in the rock climbing session and in the gym and in the natural cliff mountains. Due to entire body weight being held by the two fingers as present in the climber, the patient presents paresthesia and loss of grip. The MRI was conducted and the patient shows atypical presence of the muscle overriding the carpal tunnel. The muscle is not only present in one hand but bilaterally. The pain is due to the hypertrophy of thi
CARPAL TUNNEL SYNDROME: Carpal tunnel syndrome is regarded as the most common entrapment neuropathy and its prevalence can be estimated by 2.7 to 5.8% as seen in the adult population ( LeBlanc & Chestia, 2011). According to the survey in United Kingdom the mean crude ratio of carpal tunnel was regarded to be found in 329 cases per 100,000 person - years along with the standardized incidence ranging to 276 (LeBlanc & Chestia, 2011). Carpal tunnel syndrome is often associated with repetitive overuse-type of injuries caused by repetitive motion and is mostly work related (LeBlanc & Chestia, 2011).
ETIOLOGICAL FACTORS: The exact etiological factors are unknown. However the following etiological factors have been considered. (LeBlanc & Chestia, 2011).
Repetitive Maneuvers
Obesity
Pregnancy
Arthritis
Hypothyroidism
Diabetes Mellitus
Trauma
Mass Lesions
Amyloidosis
Sarcoidosis
Multiple Myeloma and
Leukemia
SYMPTOMS: According to LeBlanc & Chestia, (2011), the patient with carpal tunnel syndrome shows pain and paresthesia in the hand mainly along the distribution of the median nerve i.e along the course of thumb, index finger and the middle finger. Gradually the symptoms of pain and paresthesia spreads towards the forearm, arm and even to the shoulder region. (LeBlanc & Chestia, 2011). The patient might report of the feeling of swelling and the fingers feeling useless, however the demarcation of swelling is not present ( LeBlanc & Chestia, 2011). The patient reports of difficulty in performing activities that requires grasp and the patient also complains frequent pain at the night time (LeBlanc & Chestia, 2011).
PHYSICAL EXAMINATION: Physical examination shows ecchymosis or abrasion in the wrist region due to acute injury to the tissue including the median nerve. (LeBlanc & Chestia, 2011). Thenar eminence atrophy might be present and is mostly associated with carpometacarpal arthritis or neuropathy. (LeBlanc & Chestia, 2011). Hypalgesia in the palmar region of the hand with diminished strength and relative weakness of the abductor pollicis brevis muscle is present due to entrapment of the median nerve (LeBlanc & Chestia, 2011). Phalens sign, tinnel sign, square wrist sign and above mention data can be utilized to a diagnostic value of history and physical examination of the carpal tunnel syndrome (LeBlanc & Chestia, 2011).
IMAGING STUDY AND THEIR SCOPES RELATED IN CARPAL TUNNEL SYNDROME
Imaging studies including MRI and Ultrasonography has played important role in the diagnosis and treatment of carpal tunnel syndrome. MRI and Ultrasonography has not only been used in diagnosing the presence of median nerve entrapment or related pathologies but furthermore the paper will state that ultrasound has also helped in healing carpal tunnel syndrome. There are varied cases presented below which shows the diagnostic validity of MRI and ultrasonography in CTS (carpal tunnel syndrome.
As in the article stated by Nguyen et al (2012), a 52 year old man shows paresthesia which is intermittent in nature and is present from the last 10 years along the course of the median nerve distribution. The patient also complains of snapping of the fingers and states that driving and typing exacerbates the symptoms. During the examination Nguyen et al (2012) found the unusual case where instead of the atrophy of the thenar eminences there was hypertrophy and increase in the mass buldge of the thenar eminences.
An MRI was performed to solve the mystery of the hypertrophy of the thenar eminences. The MRI shows linear strands of fat infiltrating into the thenar muscles which is different from the diffuse fibro fatty change associated with advance muscular atrophy as seen in regular CTS. The MRI shows globular enlargement of the median nerve and linear cable like appearance of the nerve fascicles surrounding the fat (Nguyen et al, 2012).
The other study is provided by Fujji et al (2009), where imaging studies have played a tremendous role in classifying the presence of epithelial sarcoma which arises directly from the perineural sheath of the median nerve and mimics the sign and sympotms of the carpal tunnel syndrome. Here the case is presented of a 33 year old man who complains of pain and weakness in the course and area of distribution of the Media nerve (Fujji et al, 2009). As the epithelial sarcoma was gradually progressing and the nodule formation where noted later, the patient was first treated conservatively, thinking the symptoms manifested of CTS. (Fujji et al, 2009). The patient then noticed the presence of nodules on the forearm region and a MRI was then performed.
Epithelial sarcoma is indolent in growth and is slow growing tumor. They are one of the kinds which are rare and malignant in nature however very aggressive on occasions (Fujji et al, 2009). As their clinical manifestations are unpredictable, according to mayo clinic 38% of patient had at least recurrence and 47% of patient had metastatic lesions and 27% of the patient dies out of the disease. So in the above mention case CTS but also helped to treat the underlying lesions.
The other study was performed by Cartwright et al (2011). The study uses the Neuromuscular ultrasound to assess the changes that occur in median nerve followed by a steroid injection. In this study participants were injected the steroid injection after conducting the nerve conduction velocity study (Cartwright et al, 2011). The affected wrist was then examined with the ultrasound technique at the end of 1 week, 1 month and 6 month respectively. The ultrasound examination included measurement of the median nerve cross-sectional area at the distal wrist crease (DWC) and mid-forearm, as well as assessment of median nerve echogenicity, mobility, and vascularity at the DWC. (Cartwright et al, 2011). The ultrasound imaging was performed using an Esoate Ultrasound Device. The results of the ultrasound study showed decrease in the median nerve cross sectional area and helped the clinician to understand the timeframe of the treatment and also to evaluate the individuals who have showed failed response to the CTS treatment. (Cartwright et al, 2012). The only limitation of this study was the small sample size, therefore the study couldn't produce the probability of its usefulness on larger populations.
As I have narrated in my thesis statement that the CTS can also be caused by the congenital presences of the atypical muscles and this is noted in the case study of a recreational climber. Here the climber is present with anomalous rare presence of the muscle which is further a cause leading to CTS. Here the recreation climber, who is a male of 41 year of age presents with the symptoms of pain and paresthesia in his palmar aspects (Unglaub et al, 2010). The atypical muscle mass is seen in MRI and is the typical cause of CTS. The patient exercises in the rock climbing session and in the gym and in the natural cliff mountains. Due to entire body weight being held by the two fingers as present in the climber, the patient presents paresthesia and loss of grip. The MRI was conducted and the patient shows atypical presence of the muscle overriding the carpal tunnel. The muscle is not only present in one hand but bilaterally. The pain is due to the hypertrophy of thi
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